Determinants of child stunting in the dryland area of East Nusa Tenggara Province, Indonesia: insights from a national-level survey

Stunting remains a critical public health issue in Indonesia, particularly in the province of East Nusa Tenggara. This region, characterized by its archipelagic dryland geography, has reported the highest prevalence of stunting among children under five from 2007 to 2021. The study aimed to examine the relationship between various characteristics of children under five and household factors with the occurrence of stunting. This observational study, with a cross-sectional design, used secondary data from the 2021 Indonesian Nutrition Status Survey, covering 7,835 children under five. We analyzed the data to identify patterns and relationships, using univariate analysis to display percentage distributions and bivariate analysis through multiple binary logistic regression tests. The results of the multiple logistic regression test showed that indicators of family characteristics such as age, gender, low birth weight, body length, possession of birth certificates, and receiving complementary feeding were all related to stunting. Additionally, household factors such as toilet type, National Health Insurance coverage, ownership of a Prosperous Family Card, and residential area were significant determinants. Factors contributing to stunting in dryland areas include a range of elements from both family characteristics—such as age, gender, birth certification, low birth weight, and initial body length, to the introduction of supplementary feeding—and household indicators, including the use of specific types of latrines (Plengsengan and Cemplung types without covers), health insurance coverage, possession of Prosperous Family Cards, and the family's residential area.


INTRODUCTION
Stunting remains a significant challenge in global health, characterized by chronic malnutrition resulting from long-term inadequate nutritional intake, causing children to be significantly shorter compared to peers of the same age.Nusa Tenggara Timur (NTT) has the highest stunting prevalence rate among the 34 provinces in Indonesia, with a rate of 20.9% as of 2021 [1].
In addition, the prevalence rate is still above the national and the World Health Organization (WHO) threshold, which is 20%.
The development and growth of children experiencing stunting are significantly impacted by various factors within their family and household environment, such as inadequate access to nutritious meals, not receiving exclusive breastfeeding, and frequent exposure to infectious diseases [2,3].These elements are embedded within the broader social context, including political and economic influences, healthcare provision, educational opportunities, socio-cultural norms, agricultural practices, food availability, and access to clean water, sanitation facilities, and a hygienic living environment.
This research aimed to investigate the relationship between various characteristics of children under five and household factors with the incidence of stunting.Furthermore, we aimed to inform the development of strategic policies and effective intervention measures to reduce the prevalence of stunting in the NTT province, addressing a key issue in the public health domain and contributing to the broader efforts to improve child health and development.

Study design and participants
This study utilized secondary district-representative data from the Indonesian Nutritional Status Survey (INSS) 2021, focusing on children under five.This study was part of a larger study titled 'Nutritional Status of Children Age 0-59 Months in Indonesia' conducted by the Indonesian Ministry of Health.The INSS, a national-scale survey, aims to determine developments in the nutritional status of children under five (stunting, wasting, and underweight) at the national, provincial, and district/city levels.The study, conducted in 2019, was carried out by the Health Research and Development Agency of the Ministry of Health in collaboration with the Central Bureau of Statistics and supported by the Secretariat of the Vice President of the Republic of Indonesia.Currently, the implementation of this survey is mandated by the Presidential Decree No. 72 of 2021 where the Ministry of Health is responsible for publishing district/city stunting prevalence data annually.The survey results also form the basis for the Ministry of Finance to determine district/city Regional Incentive Funds as well as material for evaluating the implementation of nutrition interventions, both specific and sensitive, carried out by the government at the central and regional levels.
The 2021 INSS collected data from 514 regencies/cities across Indonesia, involving 14,889 census blocks and 153,228 children under five.This comprehensive dataset has been integrated with the National Socioeconomic Survey.Data was collected by trained enumerators with background in nutrition and following strict health protocols, including electronic records, disinfection of instruments, and personal protective equipment use.Additionally, 61 technical assistants across five regions ensured scientific, ethical, and health protocol compliance during data collection.This data was then processed into national, provincial, and district/city achievements.
This observational, analytical, cross-sectional study used individual secondary data from the Indonesian Nutritional Status Survey in 2021 in East Nusa Tenggara Province.Data were collected with the official permission of the Health Development Policy Agency, Ministry of Health.This study included 7,835 children aged 0-59 months living in the dryland area of the archipelago of East Nusa Tenggara Province.The primary outcome was stunting, defined by the WHO-Anthro program as a height-for-age z-score index value of less than -2 standard deviations.Other independent variables included in the study consisted of child and household factors.Child-related factors were categorized into three main categories: (1) child characteristics, including age, sex, birth weight, length at birth, and ownership of a birth certificate; (2) disease history, covering conditions like acute respiratory infection (ARI), diarrhea, and worm infections; and (3) health behavior, focusing on health integrated post-visit, breastfeeding practices, and the provision of supplementary feeding.The household factors include toilet type, national or local government health insurance ownership, Kartu Keluarga Sejahtera (KKS) card ownership, and residential areas.These factors and the specific characteristics of children under five are treated as explanatory variables, with their operational definitions provided below: • Low birth weight: Children born weighing less than 2,500 grams.

•
Birth length: Length at birth less than 48 centimeters.

Population and subjects
The INSS involved 153,228 households with children under five years old across 14,889 census blocks.The study specifically targeted households with children under five and their mothers or caregivers who participated in the survey in 2021.The subjects were the caregivers of the infants and also the infants whose mothers participated in the study.The inclusion criteria were: 1) residing in East Nusa Tenggara Province, Indonesia, 2) caregiver of the infant and the infant whose mother was interviewed in the survey, and 3) willing to participate in the study.Exclusion criteria included families that relocated outside East Nusa Tenggara Province or could not be contacted.

Sampling procedure
The sampling procedure of this study was based on the sampling procedure of the previous national study called the National Socio-Economic Study in March 2021.Initially, 22 districts were chosen, and from each village within these districts, a minimum proportionate number of households were chosen as potential participants using stratified two-stage sampling.

Data analysis
Data analysis included data coding, editing, entry, and cleaning.The univariate, bivariate, and multivariate analyses were performed with the STATA 14 program using Complex Survey Analysis.First, the univariate analysis was performed to obtain an overview of the frequency distribution.Then, bivariate analysis was performed using the chi-square test with a significance level (P = 0.05) and 95% confidence interval (CI) to assess the relationship between child-specific factors (characteristics of children under five, disease history, and health behavior history) and household factors.Furthermore, multivariate analysis was performed using logistic regression to investigate the impact of several independent variables on stunting incidence.

RESULTS
The analysis of the nutritional status of children aged 0 to 60 months, based on Height-for-Age Z-scores (HAZ), revealed critical insights into their growth patterns and potential factors contributing to stunted growth.The gender distribution among children aged 12 to 47 months (± 20%) was nearly equal, with females comprising 50.48% and males 49.52%.The data also showed that the majority (57.47%) of children under five did not have a birth certificate at birth, although they mostly had normal birth weight (83.35%) and length (75.55%).The data further indicated that during their early years, most toddlers encountered several health issues, such as infectious diseases (95.63%), diarrhea (85.96%), and helminthiasis (98.32%) (Table 1).Most mothers (93.77%) used the Posyandu (Integrated Services Post) for regular health monitoring of their children, contributing to a high rate of full immunization (61.49%) and appropriate vitamin A supplementation (76.38%).However, more than 72.12% of children under five did not receive adequate or complete exclusive breastfeeding.Moreover, interviews with mothers of children under five revealed that 79.70% of children who were malnourished were not involved in a supplementary feeding program.
Most families of children under five lived in rural areas and did not have basic health insurance (78.44%) or family welfare cards (74.98%) (Table 2).However, most families of children under five (88.99%) already had a healthy toilet with a type of Gooseneck toilet (82.77%).The logistic linear regression model was obtained (Table 6): The result showed that the chance of a child experiencing stunting with the above characteristics was 0.98 or 98%.

DISCUSSION
The results showed a decrease in the prevalence of stunting in the province of NTT, where in 2021, there was a significant decrease of 3.02% compared to 2018 (39.51%) and 7.33% compared to 2019 (43.82%).However, most regencies/cities in the NTT province still have stunting rates above 30%.The three regencies/cities with the highest stunting rates were South Central Timor Regency, North Central Timor Regency, and Alor Regency.In South Central Timor Regency, for instance, the 2020 data from the local government highlighted significant socioeconomic challenges, with 37,320 individuals living in extreme poverty out of a total population of 455,410.In addition, only 60.04% or 69,602 households had proper sanitation.These conditions are identified as significant contributors to the community's health vulnerability.
The prevalence of stunting, which exceeded 40%, indicates a public health problem that requires immediate intervention.The multivariate analysis revealed significant differences across various characteristics of children under five -such as gender, birth certificate ownership, low birth weight, and body lengthwith age being the only non-significant factor in the 6-11-month group.Children aged 36-47 months had a higher likelihood of stunting compared to those aged 0-5 months.These findings align with a study from Rwanda, which also identified an increased risk of stunting with age [4].Research indicates that children aged 6-23 months have a lower risk compared to those aged 24-59 months.Similarly, a study conducted in Dale Woreda, Southern Ethiopia, highlighted that a child's age significantly influences the risk of stunting.Particularly, children who experience stunting before the age of two face substantial challenges in overcoming chronic nutritional deficiencies due to the entrenched nature of malnutrition at this critical developmental phase [5].
Furthermore, the study indicated that male participants were more susceptible to stunting, corroborating findings from the Mozambique Region, which found that boys in the 0-59 month age group were twice as likely to experience stunting [6].Boys were more likely to experience malnutrition from the beginning Table 3 shows that age was significantly associated with stunting (P < 0.05) with a risk of 1.38-3.23 times.Additionally, factors such as exclusive breastfeeding, low birth weight, birth length, and ownership of birth certificates were also associated with the incidence of stunting (P < 0.05), with the risk being 1.19 to 1.76 times greater.On the other hand, factors including gender, infectious diseases, diarrhea incidence, frequency of Posyandu visits, vitamin A supplementation, and participation in supplementary food programs were correlated with stunting incidence.These factors can potentially act as protective elements, reducing the likelihood of stunting by a factor of one.
Most family characteristic factors were associated with stunting (Table 4).These factors were ownership of latrines and the types of latrines used, ownership of a basic health insurance card, and region of residence (P < 0.05), with a risk opportunity of up to 1.36-1.81times greater.Conversely, owning a family card was also linked to stunting incidence but as a protective factor, reducing the likelihood of stunting by 0.61 to 0.80 times.
The multivariate analysis showed that age, gender, possession of a birth certificate, low birth weight, body length at birth, supplementary feeding, ownership of uncovered and uncovered pit latrines, ownership of basic health insurance, ownership of Prosperous Family Card, and area of residence were jointly associated with the incidence of stunting (P < 0.05) in the dryland islands of East Nusa Tenggara province from 2017-2021 with a risk of 1.26-2.85times greater (Table 5).ally, the scarcity of clean water exacerbates the risk of diarrheal diseases, further hindered by the lack of clean living habits, such as regular handwashing and sanitation practices.These health challenges critically contribute to the higher incidence of stunting, with infectious diseases diminishing children's appetite and compromising their immune systems, thereby exacerbating malnutrition [5,23,24].Furthermore, the analysis revealed that while health behaviors like receiving supplementary feeding (PMT) were associated with stunting, breastfeeding and attendance at Posyandu (integrated health services post) did not show a significant impact on stunting rates.The rate of exclusive breastfeeding for infants aged 0-5 months in NTT was low (75%) and remains below the national target (93%), suggesting a potential risk factor for stunting.This is similar to another study where the exclusive breastfeeding factor played a major role in determining stunting [3].However, certain studies, such as research conducted in Kupang Regency, have reported no significant relationship between exclusive breastfeeding and the incidence of stunting.This study found that a considerable majority of children under five (66.1%) received exclusive breastfeeding adequately during the first six months of life or had a history of exclusive breastfeeding [21].Despite varying findings across studies, the importance of exclusive breastfeeding -recommended by the Ministry of Health for the first year of life and complemented by solid foods from six months, with WHO guidelines advocating for continuation up to two years -is underscored as a key determinant in addressing stunting [25][26][27][28].Observational and interview data from various studies suggest several reasons behind the low rates of exclusive breastfeeding in NTT, including prevailing beliefs that exclusive breastfeeding is not mandatory, mothers experiencing nipple pain or injuries, insufficient milk production, and cultural or familial restrictions against breastfeeding.These factors significantly contribute to the challenge of increasing exclusive breastfeeding coverage in the region.Furthermore, the bivariate results showed a relationship between a history of immunization and vitamin A supplementation with the incidence of stunting.Immunization plays a crucial role in enhancing the body's immunity, protecting children from infections that can compromise their appetite and nutrient intake, ultimately disrupting growth hormone activity and of the fetal period, which can be related to socioeconomic factors.In addition, boys spend more time outside the home, playing with other boys, resulting in greater energy expenditure and exposure to infectious diseases [7].
The analysis also revealed that toddlers born with LBW were 1.76 times more likely to experience stunting compared to those with regular birth weights.Consistent with multiple studies, LBW is identified as a primary risk factor for stunting [8][9][10].Children with LBW are at high risk of experiencing slower linear growth than children with normal LBW [11].In addition to birth weight, children under five with abnormal birth length (<48 cm) also had a 1.17 times chance of experiencing stunting compared to toddlers with normal body length.This condition underscores the importance of fetal growth, which can be influenced by genetic factors and maternal nutritional intake during pregnancy.LBW, signaling poor nutritional status from pregnancy, has a profound impact on fetal development and is a critical factor in the occurrence of stunting [8,12].This malnutrition can restrict the supply of nutrients through the placenta, affecting fetal growth [13][14][15].Consequently, children born with LBW are highly likely to experience stunted growth and associated health issues in their early years, illustrating the significant role of prenatal nutrition in preventing stunting [8,[16][17][18][19][20].
The bivariate analysis highlighted significant differences in the incidence of childhood illnesses such as ARI and diarrhea, except for helminthiasis, in relation to stunting.However, multivariate analysis showed that the history variable had no relationship to stunting.This outcome contrasts with findings from studies in Kupang and Timur Tengah Utara Regencies, NTT, where a notable link between infectious disease history and stunting was observed.In those studies, children under five with a history of infectious diseases were found to be three times more likely to experience stunting, highlighting the significant impact of illnesses like ARI, diarrhea, and pneumonia on child health and growth [21,22].
Stunting is intricately connected not only to growth challenges but also to increased susceptibility to diseases.Factors such as exposure to smoke within the household and living in traditional houses (Loppo in NTT) with poor ventilation and dirt floors can significantly increase the risk of ARI and pneumonia.Addition-that toddlers who do not have a JKN/Jamkesda card experience a higher incidence of stunting (39%).
The results of this study showed that toddlers who lived in rural areas had a higher chance of experiencing stunting, which can be attributed to socioeconomic and cultural factors.Data from the Indonesian Central Statistic Agency (BPS) underscore the economic challenges faced by the residents of NTT, with over 21% of the population living below the poverty line.This translates to approximately 1146.32 individuals per Regency/City in East Nusa Tenggara Province, with a daily per capita income of IDR 403,005.Most individuals in the NTT province work in the agricultural sector.However, economic analysis indicates that this sector contributes only 28.89% to the Gross Regional Domestic Product (GRDP) at Current Prices in NTT Province [32].This disparity has direct implications for the purchasing power of families with children under five, impacting the nutritional adequacy of young children.
Furthermore, the economic status of pregnant women has been shown to influence maternal health, which in turn correlates with the occurrence of stunting in newborns [33][34][35].Moreover, mothers engaged in farming often have limited time for childcare and meal preparation at home, potentially affecting children's dietary patterns and nutritional intake [36,37].The results showed that food diversity, dietary patterns, and the amount of food were associated with the incidence of stunting [38][39][40].